Cholecystitis and Cholelithiasis

Nursing Care Plans

PRESENTATION BY: LOUELLA G. RAMOS, R.N.

Cholecystitis is the inflammation of the gallbladder,

usually associated with gallstones impacted in the cystic
duct. Stones (calculi) are made up of cholesterol, calcium
bilirubinate, or a mixture caused by changes in the bile
composition. Gallstones can develop in the common bile
duct, the cystic duct, hepatic duct, small bile duct, and
pancreatic duct. Crystals can also form in the submucosa
of the gallbladder causing widespread inflammation.
Acute cholecystitis with cholelithiasis is usually treated
by surgery, although several other treatment methods
(fragmentation and dissolution of stones) are now being

Choleslithiasis, stones or calculi in the gallbladder, results

from changes in bile components. Gallstones are made of
cholesterol, calcium bilirubinate, or a mix of cholesterol
and bilirubin. They arise during periods of sluggishness in
the gallbladder due to pregnancy, hormonal
contraceptives, diabetes mellitus, celiac disease, cirrhosis
of the liver, and pancreatitis.

PSYCHOLOGIC

ASSESSMENT
S: Ano na
mangyayari
sa akin? as
verbalized
by the pt.
O: Restless

DIAGNOSIS
Deficient
Knowledge

PLANNING

INTERVENTION

Explain
After 8 hours
of nursing
reasons for
interventions
test
Related to :
the pt will able procedures
Lack of
to:
and
knowledge/reca Verbalize
preparations
ll
understandin
as needed.
g of disease
Information
process,
Review
misinterpretati
prognosis,
disease
on
potential
process and
complications prognosis.
As evidenced
.
Discuss
by:
hospitalizatio
Questions;
Verbalize
n and
request for
understandin
prospective
information
g of
treatment as
therapeutic
indicated.
Statement of
needs.
Encourage
misconception
questions,
Initiate
expression of
necessary
concern.

RATIONALE

EVALUATION

Information
can decrease
anxiety,
thereby
reducing
sympathetic
stimulation.

After 8 hours
of nursing
interventions
the pt was
able to:
Verbalize
understandin
g of disease
process,
prognosis,
potential
complications
.

Provides
knowledge
base from
which patient
can make
informed
choices.
Effective
communicati
on and
support at
this time can
diminish
anxiety and

Verbalize
understandin
g of
therapeutic
needs.
Initiate
necessary

ASSESSMENT

DIAGNOSIS

PLANNING
treatment
regimen.

INTERVENTION

RATIONALE

Review drug
regimen,
possible side
effects.

Gallstones
often recur,
necessitating
long-term
therapy.

Discuss
weight
reduction
programs if
indicated

Note: Women
of childbearing
age should be
counseled
regarding birth
control to
prevent
pregnancy and
risk of fetal
hepatic
damage.
Obesity is a
risk factor
associated
with

EVALUATION
treatment
regimen.

ASSESSMEN
T

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
& weight loss
is beneficial in
medical
management
of chronic
condition.

Instruct patient
to avoid
food/fluids high
in fats (pork,
gravies, nuts,
fried foods,
butter, whole
milk, ice cream),
gas producers
(cabbage,
beans, onions,
carbonated
beverages), or
gastric irritants (
spicy foods,

Limits or
prevents
recurrence of
gallbladder
attacks.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Review signs
and
symptoms
requiring
medical
intervention:
recurrent
fever;
persistent
nausea and
vomiting, or
pain;
jaundice of
skin or eyes,
itching; dark
urine; claycolored
stools; blood
in urine,
stools,
vomitus; or
bleeding

Indicative of
progression
of disease
process and
development
of
complication
s requiring
further
intervention.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Recommend
Promotes
resting in
flow of bile
semi-Fowlers and general
position after
relaxation
meals.
during initial
digestive
process.
Suggest
patient limit
gum
chewing,
sucking on
straw and
hard candy,
or smoking.
Discuss
avoidance of
aspirincontaining

Promotes gas
formation,
which can
increase
gastric
distension
and
discomfort.
Reduces risk
of bleeding
related to
changes in

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

products,
forceful
blowing of
nose, straining
for bowel
movement,
contact sports.

time, mucosal
irritation, and
trauma.

Recommend
use of soft
toothbrush,
electric razor.

Reduces risk
of bleeding
related to
changes in
coagulation
time,
mucosal
irritation, and
trauma

EVALUATION

ELIMINATION

ASSESSMENT
S: Nasusuka
ako as
verbalized by
the pt.
O: (+)
Vomiting
(+) gastric
hypermotility
(+) Poor skin
turgor
(+) Body
weakness

DIAGNOSIS

PLANNING

Risk for
Deficient Fluid
Volume

After 8 hours
of nursing
interventions
the patient
will be able to
Demonstrate
adequate fluid
balance
evidenced by
stable vital
signs, moist
mucous
membranes,
good skin
turgor,
capillary refill,
individually
appropriate
urinary
output,
absence of
vomiting.

INTERVENTION

RATIONALE

Maintain
To provide
accurate
information
record of I&O, about fluid
noting output status and
less than
circulating
intake,
volume
increased
needing
urine specific
replacement.
gravity.
Assess skin
and mucous
membranes,
peripheral
pulses, and
capillary
Prolonged
refill.
vomiting,
gastric
Monitor for
aspiration,
signs and
and restricted
symptoms of
oral intake
increased or
can lead to
continued
deficits in

EVALUATION
After 8 hours
of nursing
interventions
the patient
was able to
Demonstrate
adequate fluid
balance
evidenced by
stable vital
signs, moist
mucous
membranes,
good skin
turgor,
capillary refill,
individually
appropriate
urinary
output,
absence of
vomiting.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

abdominal
cramps,
weakness,
twitching,
seizures,
irregular heart
rate,
paresthesia,
hypoactive or
absent bowel
sounds,
depressed
respirations.

sodium,
potassium,
and chloride.

Eliminate
noxious
sights or
smells from
environment.

Reduces
stimulation of
vomiting
center.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Perform
frequent oral
hygiene with
alcohol-free
mouthwash;
apply
lubricants.

Decreases
dryness of
oral mucous
membranes;
reduces risk
of oral
bleeding.

Use small Reduces

gauge
trauma, risk
needles for
of bleeding or
injections
hematoma
and apply
formation.
firm pressure
for longer
than usual
after
venipuncture
.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION
Assess for
unusual
bleeding: oozing
from injection
sites, epistaxis,
bleeding gums,
ecchymosis,
petechiae,
hematemesis or
melena.

RATIONALE

Prothrombin
is reduced
and
coagulation
time
prolonged
when bile
flow is
obstructed,
increasing
risk of
bleeding or
Keep patient NPO hemorrhage.
as necessary.
Decreases GI
secretions
Insert NG tube,
and motility.
connect to
suction, and
To rest the GI
maintain patency Tract
as indicated.

EVALUATION

REST & COMFORT

ASSESSMENT
S: Hindi ako
makatulog sa
sakit ng tiyan
ko as
verbalized by
the pt
Pain Scale:
8/10
O: (+) Facial
grimace
(+) guarding
behavior
BP=140/90mm
Hg
PR= 100bpm

DIAGNOSIS
Acute Pain
related to
obstruction/
ductal spasm

PLANNING

INTERVENTION

RATIONALE

Note
Severe pain
After 8 hours
of nursing
response to
not relieved
interventions
medication,
by routine
the patient will
and report
measures
be able to:
to physician
may indicate
if pain is not
developing
Report pain
being
complication
is relieved/
relieved.
s or need for
controlled.
further
intervention.
Demonstrat
Bedrest in
e use of
Promote
relaxation
low-Fowlers
skills and
bedrest,
position
diversional
allowing
reduces
activities as
patient to
intraindicated
assume
abdominal
for
position of
pressure;
individual
comfort.
however,
situation.
patient will
naturally
assume least

EVALUATION
After 8 hours
of nursing
interventions
the patient
was able to:
Report pain
is relieved/
controlled.
Demonstrat
e use of
relaxation
skills and
diversional
activities as
indicated
for
individual
situation.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Use soft or
Reduces
cotton linens;
irritation and
calamine lotion, dryness of the
oil bath; cool or skin and itching
moist
sensation.
compresses as
indicated.
Encourage use
of relaxation
techniques.
Provide
diversional
activities.

Promotes rest,
redirects
attention, may
enhance coping.

Make time to
listen to and
maintain
frequent
contact with
patient.

Helpful in
alleviating
anxiety and
refocusing
attention, which
can relieve pain.

EVALUATIO
N

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Sedatives:
Promotes rest
phenobarbit and relaxes
al
smooth muscle,
relieving pain.
Narcotics:
meperidine
hydrochlori
de
(Demerol),
morphine
sulfate

Given to reduce
severe pain.
Morphine is
used with
caution
because it may
increase
spasms of the
sphincter of
Oddi, although
nitroglycerin
may be given
to reduce
morphineinduced
spasms if they
occur.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Smooth
muscle
relaxants:
papaverine
(Pavabid),
nitroglycerin,
amyl nitrite

Relieves
ductal spasm.

These natural
Chenodeoxyc
bile acids
holic acid
decrease
(Chenix),
cholesterol
ursodeoxycho synthesis,
lic acid (Urso, dissolving
Actigall)
gallstones.
Success of
this
treatment
depends on
the number
and size

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
of gallstones
(preferably
three or fewer
stones smaller
than 20 min in
diameter)
floating in a
functioning
gallbladder.

Antibiotics.
To treat
infectious
process,
reducing
inflammatio
n.

EVALUATION

SAFETY

ASSESSMENT
S: Nilalamig
ako as
verbalized by
the pt.
O: Temp=38.5
C
(+) chills
(+) Redness
and swelling
at the incision
site
(+) Purulent
discharge

DIAGNOSIS
Risk for
infection,
related to
potential
bacterial
contamination
of abdominal
cavity

PLANNING

INTERVENTION

RATIONALE

Instruct the
Hand washing
After 8 hrs.
of nursing
pt and
remains the
interventions
caregiver to
most effective
the pt will
wash hands
method of
remain free
before
infection
of infection
contact with
control.
as evidenced
the
by healing
postoperative
wound or
pt.
incision that
Aseptic
is free of
Teach use
technique
redness,
aseptic
prevents
swelling,
technique
transmission
purulent
during
of bacterial
discharge,
dressing
infections to
and pain,
change, or
the area.
and by
handling or
normal body
manipulating
temperature
of tubes and
within 48
drains.
hrs.
postoperativ

EVALUATION
After 8 hrs.
of nursing
intervention
s the pt was
able to
remain free
of infection
as
evidenced
by healing
wound or
incision that
is free of
redness,
swelling,
purulent
discharge,
and pain,
and by
normal body
temperature
within 48

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Ensure the
surgical
tubes and
drains are
not
inadvertently
interrupted
(opened).
Securely tape
connectors
and pin
extension or
drainage
tubing to the
pt.'s clothing.

Opening
sterile
systems
allows access
by pathogens
and puts the
pt at risk for
infection to
the area.
Drains may be
left in place until
the first return
visit to the
surgeon (about
7 days), if not
removed at the
time of
discharge.

Instruct the
patient and
caregiver in
administratio
n

Antibiotics are
necessary for
the treatment of

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

of antibiotics
Antipyretics will
and antipyretics reduce fever and
as prescribed.
promote
comfort.

EVALUATION

OXYGENATION

ASSESSMENT
S: Masakit
kapag nag
uubo, hirap
huminga as
verbalized by
the pt
O: Poor
coughing
effort
Shallow
breathing
Splinting
respirations

DIAGNOSIS
Ineffective
Breathing
pattern
related to:
Abdominal
incision pain
Abdominal
distention
compromisin
g lung
expansion
Sedation

Lack of
RR = 24 cpm
knowledge

PLANNING

INTERVENTION

RATIONALE

EVALUATION

After 8 hours
of nursing
interventions
the pt will be
able to
maintain an
effective
breathing
pattern as
evidenced by
a respiratory
rate, non
labored deep
respirations,
ability to use
incentive
spirometer
correctly, &
clear lung
sounds.

Assess rate and

depth of
respirations.

Respirations are
typically
shallow,
because the
least amount of
excursion is less
painful when an
abdominal
incision is
present. Also
higher the
incision, the
more the
breathing is
affected.

After 8
hours of
nursing
intervention
s the pt was
able to
maintain an
effective
breathing
pattern as
evidenced
by a
respiratory
rate, non
labored
deep
respirations,
ability to
use
incentive
spirometer
correctly, &

Auscultate lung
sounds at least
every 4 hours
postoperatively.

The bases of the

lungs are least
likely to be
ventilated;
therefore lung
sounds may be

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION
Observe for
splinting.

Elevate head of
bed at least 30
degrees.

Encourage the
pt to do deep
breathing
exercises.

RATIONALE
Splinting refers
to the conscious
minimization of
an inspiration to
reduce the
amount of
discomfort
caused by full
expansion.
This position
puts the least
strain on
abdominal
muscles and
enhances
diaphragmatic
excursion.
Keeps the alveoli
from collapsing.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Help the pt
splint the
abdominal
incision by
using hands or
pillow.

Splinting the
incision eases
discomfort of
coughing and
taking deep
breaths.

Administer
oxygen as
prescribed

Promoting lung
expansion and
oxygenation of
the tissues is a
goal of the pt
with atelectasis.

EVALUATION

NUTRITION

ASSESSMENT

DIAGNOSIS

PLANNING

S: Wala
siyang ganang
kumain as
verbalized by
the watcher

Imbalanced
nutrition:
Less than
body
requirement
s, related to
anorexia and
recent
weight loss

After 8 hours of
nursing
interventions
the patient will
be able to:

O : (+)
Vomiting

INTERVENTION

RATIONALE

Calculate
Identifies
caloric intake. nutritional
Keep
deficiencies
comments
and/or needs.
about
Focusing on
appetite to a
problem
Report relief of
minimum.
creates a
nausea/vomitin
negative
g.
atmosphere
and may
Demonstrate
interfere with
progression
intake.
toward desired
weight gain or Weigh as
Monitors
maintain
indicated.
effectiveness
weight as
of dietary
individually
plan.
Consult with
appropriate.
patient about Involving
likes and
patient in
dislikes,
planning
enables

EVALUATION
After 8 hours
of nursing
interventions
the patient
was able to:
Report relief
of
nausea/vomiti
ng.
Demonstrate
progression
toward
desired
weight gain or
maintain
weight as
individually
appropriate.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION
foods that cause
distress, and
preferred meal
schedule.
Provide a
pleasant
atmosphere at
mealtime;
remove noxious
stimuli.
Provide oral
hygiene before
meals.
Offer
effervescent
drinks with
meals, if
tolerated.

RATIONALE
to have a
sense of
control and
encourages
eating.
Useful in
promoting
appetite/redu
cing nausea.
A clean
mouth
enhances
appetite.
May lessen
nausea and
relieve gas.
Note: May be

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
contraindicate
d if beverage
causes gas
formation/gast
ric discomfort.

Assess for
abdominal
distension,
frequent
belching,
guarding,
reluctance to
move.
Ambulate
and increase
activity as
tolerated.

Nonverbal
signs of
discomfort
associated
with impaired
digestion, gas
pain.

Helpful in
expulsion of
flatus,
reduction

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Consult with
dietitian or
nutritional
support team
as indicated.

RATIONALE
of abdominal
distension.
Contributes to
overall recovery
and sense of
well-being and
decreases
possibility of
secondary
problems
related to
immobility
(pneumonia,
thrombophlebiti
s)
Useful in
establishing
individual
nutritional
needs and most
appropriate

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Begin low-fat Limiting fat

liquid diet
content
after NG
reduces
tube is
stimulation of
removed.
gallbladder
and pain
associated
with
incomplete
fat digestion
and is helpful
in preventing
recurrence.
Advance diet
as tolerated,
usually low Meets
fat, highnutritional
fiber. Restrict requirements
gaswhile
minimizing
stimulation of

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

producing
foods (onions,
cabbage,
popcorn) and
foods or fluids
high in fats
(butter, fried
foods, nuts).
Promotes
Administer
digestion
bile salts:
and
Bilron,
absorption
Zanchol,
of fats, fatdehydrochol
soluble
ic acid
vitamins,
(Decholin),
cholesterol.
as
Useful in
indicated.
chronic
cholecystitis
.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION
Monitor
laboratory
studies:
BUN, pre
albumin,
albumin,
total
protein,
transferrin
levels.
Provide
parenteral
and/or
enteral
feedings as
needed.

RATIONALE
Provides
information
about
nutritional
deficits or
effectiveness
of therapy.

Alternative
feeding may
be required
depending on
degree of
disability and
gallbladder
involvement
and need for
prolonged
gastric rest.

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Maintain NPO Removes

status, insert
gastric
and/or
secretions
maintain NG
that stimulate
suction as
release of
indicated.
cholecystokini
n and
gallbladder
Administer
contractions.
medications
as indicated:
Anticholinergi
cs: atropine,
Relieves reflex
propanthelin
spasm and
e (Pro-Banthsmooth
ne)
muscle
contraction
and assists
with pain
management.

EVALUATION

THANK YOU FOR

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